Night to Unite Registration Form

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Your Name:*

Your Address:*

City:

State:

Zip:

Preferred Telephone:*

Other Telephone:

E-Mail Address:

Block Party Location:*

Date of Block Party:*

Estimated Start Time:*

AM or PM*

Estimated End Time:*

AM or PM

Requests for Special Visits (We will try to accommodate as many requests as possible)

McGruff

Fire

Police

If requesting a special visit, when is the best time to arrive?*

Number of Adults Expected:

Number of Children (10 yrs and under):

Are you planning to block off any streets?

YES

NO

Which streets are you planning to block off?

Barricade tape and directions for use will be available and can be picked up at the Police Department Monday, July 30 through Friday, August 3 from 8 a.m.- 4:30 p.m. Please be aware we are unable to block certain streets. You will be contacted if your street cannot be blocked due to high traffic volume.

All parties are considered public- City staff and local media may attend to take photos and/or video.

Additional Comments:

Unless restricted by law, all correspondence to and from Roseville City government offices, including information submitted through electronic forms such as this one, may be public data subject to the Minnesota Data Practices Act and/or may be disclosed to third parties.